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The Patient's Story

Mr L is an inmate in his early 40s incarcerated in a state correctional facility, where he is serving a 10-year sentence for manslaughter. He was transferred to a prison treatment setting after he developed back pain and had bloody sputum. His hemoptysis was evaluated with chest radiography, the results of which were abnormal. A subsequent computed tomography scan showed a right upper lobe mass; a biopsy confirmed adenocarcinoma. Magnetic resonance imaging to evaluate his back pain revealed metastatic invasion of T12 and L1, confirming stage IV disease.

Dr V, the prison physician, referred Mr L to a cancer center at a university medical center, where he completed a course of radiation and received first-line chemotherapy. Unfortunately, a reassessment of his disease by repeat computed tomography after several months of chemotherapy showed tumor progression. A second chemotherapy regimen was undertaken, but it also failed to stop disease progression. Mr L was then referred to hospice inside the correctional facility. He was simultaneously referred for medical parole.

Perspectives

A Perspectives editor interviewed Mr L; the prison's internist, Dr V; and the prison's hospice caregiver coordinator, Dr S, 1 year after initial diagnosis. Dr S suggested Mr L as a hospice patient who would be willing to talk about his own disease. Mr L's interview was conducted by telephone in the office of his caseworker on the prison staff. A student intern was present when the interview took place; Dr V and Dr S were not present during Mr L's interview.

DR V (PRISON PHYSICIAN):Mr L is in his early 40s and has adenocarcinoma of the lung that has metastasized to one of the thoracic vertebral bodies. As such, the tumor is incurable. He was diagnosed [1 year ago]. He has initially responded to radiation, both to the primary site and the known vertebral metastases. Lately there has been some discussion among the oncologists as to how effective the treatment has been…My role is to admit inmates from any of the 4 correctional institutions in the area into a local community hospital for medical treatment…[and] to supervise treatment of inmates…on our medical wing. While [Mr L] is here, I am his primary care physician. I'm not an oncologist, so I have to defer to the experts on the treatment of his cancer, but I take care of his primary medical needs, like any other internist would.

MR L (PATIENT/INMATE):I'm in the State Reformatory since [4 years ago]. I'm in here on a second-degree manslaughter charge [for] 10 years. I got the diagnosis [last year]. After I got my diagnosis, I was sent to this facility for treatment…I was supposed to have surgery done [the following month]. It took the prison 2 months to get me out to the doctors. By that time, it had turned malignant and gone into all of my body…The cancer started in my ...